International Journal of Cardiology 186 (2015) 93–95
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Uncertainties in insurances for adults with congenital heart disease☆,☆☆ M.A. Sluman a,b,⁎, S. Apers c, B.J. Bouma a, J.P. van Melle d, C.H. Peels e, M.C. Post f, W.M. Waskowsky g, P. Moons c, B.J.M. Mulder a,b,⁎ a
Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands KU Leuven — University of Leuven, Department of Public Health and Primary Care, Leuven, Belgium d Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands e Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands f Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands g Department of Cardiology, Isala Hospital, Zwolle, The Netherlands b c
a r t i c l e
i n f o
Article history: Received 17 February 2015 Accepted 17 March 2015 Available online 18 March 2015 Keywords: Heart defects Congenital Quality of life Insurance Mortgage
To the Editor: Despite improved life expectancy and often few physical restrictions, a substantial number of adults with congenital heart disease (CHD) still experiences restrictions in daily life in the areas of employment, insurances and mortgages [1–4]. Life expectancy of, for example, patients with Marfan syndrome has increased with more than 25% since 1970 [5]. Although interest and insights in late survival of adults with CHD are increasing globally, including substantial scientific contributions from European countries and the Netherlands [6], difficulties with insurance applications do not seem to decrease [7]. Therefore, we studied the presence of constraints in health, life and disability ☆ All authors take full responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ☆☆ Acknowledgment of grant support: none. ⁎ Corresponding authors at: Department of Cardiology, Room B2-240, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail addresses: [email protected] (M.A. Sluman), [email protected] (S. Apers), [email protected] (B.J. Bouma), [email protected] (J.P. van Melle), [email protected] (C.H. Peels), [email protected] (M.C. Post), [email protected] (W.M. Waskowsky), [email protected] (P. Moons), [email protected] (B.J.M. Mulder).
http://dx.doi.org/10.1016/j.ijcard.2015.03.208 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
insurances and mortgages applications in adults with CHD in comparison to a reference group [8]. 1. Methods Data were derived from a questionnaire which was sent to a random selection of adults with CHD from five hospitals (i.e., two tertiary referral centers and three regional centers) participating in the Dutch nationwide CONgenital CORvitia (CONCOR) registry. CONCOR facilitates research on the course and outcome of adult CHD [9]. Between 2001 and 2013, over 14,000 adults with CHD were included in CONCOR after providing informed consent. Data collection for this study ran from June 2013 until September 2014. The questionnaire included information on demographic items (i.e., sex, age, educational, occupational and relational status) and on applications and potential constraints for a health, disability or life insurance or mortgage. Results were compared to those from a reference group, obtained from the personnel of the participating hospitals, several random companies, administration organizations and people randomly passing by. Additional medical information on cardiac function, functional class and performance status was collected to search for clinical characteristics associated with constraints in the application. Under Dutch law, ethical approval for questionnaire studies is not required. Statistical analyses included the Chisquare test for categorical variables and the Mann–Whitney U test for continuous variables. All data were analyzed per CHD severity (i.e., mild or moderate to severe). Multivariable logistic regression analyses were performed adjusted for age, sex and socioeconomic status (i.e., educational and occupational attainment) and presented as odds ratios (ORs) with 95% confidence intervals (CI). Associations were considered significant if the 95% CI did not cover the value 1. The level of statistical significance was set at a p ≤ 0.05. Statistical analyses were conducted with the Statistical Package for the Social Sciences (SPSS, version 21.0, Inc., Chicago, IL, USA). 2. Results Of the 406 randomly selected patients, 237 patients completed the questionnaire (response rate 58%). Twenty patients refused to
94
M.A. Sluman et al. / International Journal of Cardiology 186 (2015) 93–95
Table 1 Socio-demographic characteristics of the study population.
Female sex, N (%) Age, median (IQR), y Personal situation, N (%): In a relationship Divorced/single/unmarried/widowed Other/unknown Education, N (%): Low (only primary school or other lower education) Higher (higher or academic education) Daily occupation, N (%): Employed Full-time paid job Part-time paid job Unemployed/job seeking Disabled Student/retired Homemaker Other CHD distribution, N (%): Mild Moderate Severe Distribution of defects, N (%) Repaired PDA/ASD/VSD Small PDA/ASD/VSD TOF CoA pulmonary valve disease Isolated aortic valve disease Marfan syndrome TGA Fontan/univentricular heart Ebstein's anomaly AVSD Other
CHD group
Reference group
p-Value
N = 237
N = 179
131 (55) 41 (31–50)
106 (59) 43 (32–54)
0.421 0.207
165 (70) 64 (27) 8 (3)
131 (73) 47 (26) 1 (1)
0.139
146 (63)
63 (35)
b0.001
84 (37)
116 (65)
153 (65) 84 (55) 69 (45) 8 (3) 25 (11) 27 (11) 12 (5) 12 (5)
158 (88) 100 (63) 58 (37) 1 (1) 1 (1) 15 (8) 4 (2) 0
0.002
96 (40) 123 (52) 18 (8)
– – –
–
42 (18) 30 (13) 26 (11) 25 (10) 21 (9) 28 (12) 16 (7) 9 (4) 6 (2) 4 (2) 3 (1) 27 (11)
– – – – – – – – – – – –
–
IQR = interquartile range; PDA = patent ductus arteriosus; ASD = atrial septal defect; VSD = ventricular septal defect; TOF = tetralogy of Fallot; CoA = aortic coarctation; TGA = transposition of great arteries; AVSD = atrioventricular septal defect.
participate, 16 were unable to participate and 7 were lost to follow-up. The remaining 126 patients never responded to our call for participation. Nonresponse analysis showed that responders were more often women (55% versus 39%, p b 0.001) and were older (median age 41 versus 36 years, p = 0.012). However, CHD severity did not differ significantly between responders and non-responders (p = 0.950). The main socio-demographic characteristics of the patients and the reference group and the distribution of the most frequent CHD diagnoses are outlined in Table 1. Employment rates were significantly lower in patients with CHD as compared to the reference group (65% versus 88%, p = 0.002). Of all patients with CHD, 40% had mild, 52% had moderate and 8% had severe CHD. The results from the questions on insurance and mortgage applications are displayed in Table 2. Insurance and mortgage application rates were significantly lower for all patients with CHD compared to the reference group, but did not differ among the different CHD severity groups. Lower disability insurance rates among patients were most likely attributable to lower employment rates. In total, 38% of patients with CHD experienced constraints in any application versus only 9% in the reference group (p b 0.001). Participants with and without constraints did not differ in age, sex, educational or employment status. Most constraints were encountered for patients with CHD in life insurance applications with significant differences in CHD severity. More specifically, patients with more severe CHD experienced more limitations (33% versus 56%, p = 0.009), of whom the majority (56%) had to pay a higher premium. Twenty percent of patients were declined for a life insurance, 15% were eventually accepted and 9% found other solutions such as an adjusted sum assured. In total, of only 38% of CHD patients medical information was requested from their treating physician. Among patients who had experienced limitations in the application process, this was the case in 70%. Additional medical information did not lead to different outcomes or other patterns in constraints and CHD severity. Only 10% of all patients who experienced limitations contacted a CHD patient association or other institution for help or advice. The association of two clinical parameters, functional New York Heart Association (NYHA) classification and left ventricular (LV) ejection fraction, with restrictions in insurance or mortgage applications was studied in 163 patients. After adjustment for age, sex, type of cardiac defect, occupational and relational status, restrictions were not associated with clinical parameters.
Table 2 Reported restrictions in insurance and mortgage application. CHD
REF N = 179
p-Valuea
p-Valueb
Adjusted ORc (95% CI)
Mild N = 96
Moderate to severe N = 141
Total N = 237
Any problem Applied, N (%) Restrictions, N (%)
90 (94) 31 (34)
126 (89) 51 (40)
216 (91) 82 (38)
174 (97) 15 (9)
0.243 0.538
0.011 b0.001
8.3 (4.3–15.9)
Health insurance Applied, N (%) Restrictions, N (%)
86 (90) 6 (7)
111 (79) 11 (10)
197 (83) 17 (9)
170 (95) 6 (4)
0.036 0.467
b0.001 0.014
3.6 (1.3–9.9)
Disability insurance Applied, N (%) Restrictions, N (%)
40 (42) 7 (18)
45 (32) 10 (22)
85 (35) 17 (20)
108 (60) 2 (2)
0.145 0.587
b0.001 0.003
11.8 (2.4–58.5)
Life insurance Applied, N (%) Restrictions, N (%)
58 (60) 19 (33)
72 (51) 40 (56)
130 (55) 59 (45)
127 (71) 3 (2)
0.180 0.009
0.002 b0.001
47.7 (13.4–170.0)
Mortgage Applied, N (%) Restrictions, N (%)
64 (67) 14 (22)
76 (54) 18 (24)
139 (59) 32 (23)
131 (73) 4 (3)
0.054 0.800
0.006 b0.001
8.4 (2.8–25.5)
CHD = congenital heart disease, REF = reference group, OR = odds ratio, CI = confidence interval. a Comparison of different CHD severities. b Comparison of total patient group to reference group. c Adjusted for age, sex, application, education and job.
M.A. Sluman et al. / International Journal of Cardiology 186 (2015) 93–95
3. Discussion and conclusion This study shows that favorable prognostic clinical factors in patients with CHD as mild defects, normal NYHA class and LV ejection fraction do not protect against constraints in insurance or mortgage applications. Despite the overall improved morbidity and prognosis, adults with CHD encountered more limitations than a reference group from the general population [10]. Providing clinical information was not associated with a reduction in constraints. Hence, clinical information did not seem to improve insight or transparency in the application process. Nowadays, accurate prognostication for most patients with CHD based on individual clinical information is possible [10,11]. We should continue to support patients in making sure essential medical information is provided and encourage insurance companies to base their decisions on clinical and epidemiological outcomes. In conclusion, there still seems to be an important gap between knowledge on CHD and transparency of the insurance application process. Applying for insurance shouldn't be so uncertain. Conflict of interest None. References [1] A.C. Zomer, I. Vaartjes, C.S. Uiterwaal, et al., Social burden and lifestyle in adults with congenital heart disease, Am. J. Cardiol. 109 (2012) 1657–1663. [2] J.L. Harrison, C.K. Silversides, E.N. Oechslin, A.H. Kovacs, Healthcare needs of adults with congenital heart disease: study of the patient perspective, J. Cardiovasc. Nurs. 26 (2011) 497–503.
95
[3] A.J. Marelli, A.S. Mackie, R. Ionescu-Ittu, E. Rahme, L. Pilote, Congenital heart disease in the general population: changing prevalence and age distribution, Circulation 115 (2007) 163–172. [4] P. Moons, L. Bovijn, W. Budts, A. Belmans, M. Gewillig, Temporal trends in survival to adulthood among patients born with congenital heart disease from 1970 to 1992 in Belgium, Circulation 122 (2010) 2264–2272. [5] M. Groenink, T.A. Lohuis, J.G. Tijssen, et al., Survival and complication free survival in Marfan's syndrome: implications of current guidelines, Heart 82 (1999) 499–504. [6] A. Kempny, R. Fernandez-Jimenez, O. Tutarel, et al., Meeting the challenge: the evolving global landscape of adult congenital heart disease, Int. J. Cardiol. 168 (2013) 5182–5189. [7] D.S. Crossland, S.P. Jackson, R. Lyall, et al., Life insurance and mortgage application in adults with congenital heart disease, Eur. J. Cardiothorac. Surg. 25 (2004) 931–934. [8] S. Apers, A.H. Kovacs, K. Luyckx, et al., Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart Disease—International Study (APPROACH-IS): rationale, design, and methods, Int. J. Cardiol. 179 (2015) 334–342. [9] E.T. van der Velde, J.W. Vriend, M.M. Mannens, C.S. Uiterwaal, R. Brand, B.J. Mulder, CONCOR, an initiative towards a national registry and DNA-bank of patients with congenital heart disease in the Netherlands: rationale, design, and first results, Eur. J. Epidemiol. 20 (2005) 549–557. [10] C.L. Verheugt, C.S. Uiterwaal, E.T. van der Velde, et al., Mortality in adult congenital heart disease, Eur. Heart J. 31 (2010) 1220–1229. [11] C.L. Verheugt, C.S. Uiterwaal, D.E. Grobbee, B.J. Mulder, Long-term prognosis of congenital heart defects: a systematic review, Int. J. Cardiol. 131 (2008) 25–32.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Uncertainties in insurances for adults with congenital heart disease☆,☆☆ M.A. Sluman a,b,⁎, S. Apers c, B.J. Bouma a, J.P. van Melle d, C.H. Peels e, M.C. Post f, W.M. Waskowsky g, P. Moons c, B.J.M. Mulder a,b,⁎ a
Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands KU Leuven — University of Leuven, Department of Public Health and Primary Care, Leuven, Belgium d Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands e Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands f Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands g Department of Cardiology, Isala Hospital, Zwolle, The Netherlands b c
a r t i c l e
i n f o
Article history: Received 17 February 2015 Accepted 17 March 2015 Available online 18 March 2015 Keywords: Heart defects Congenital Quality of life Insurance Mortgage
To the Editor: Despite improved life expectancy and often few physical restrictions, a substantial number of adults with congenital heart disease (CHD) still experiences restrictions in daily life in the areas of employment, insurances and mortgages [1–4]. Life expectancy of, for example, patients with Marfan syndrome has increased with more than 25% since 1970 [5]. Although interest and insights in late survival of adults with CHD are increasing globally, including substantial scientific contributions from European countries and the Netherlands [6], difficulties with insurance applications do not seem to decrease [7]. Therefore, we studied the presence of constraints in health, life and disability ☆ All authors take full responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ☆☆ Acknowledgment of grant support: none. ⁎ Corresponding authors at: Department of Cardiology, Room B2-240, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail addresses: [email protected] (M.A. Sluman), [email protected] (S. Apers), [email protected] (B.J. Bouma), [email protected] (J.P. van Melle), [email protected] (C.H. Peels), [email protected] (M.C. Post), [email protected] (W.M. Waskowsky), [email protected] (P. Moons), [email protected] (B.J.M. Mulder).
http://dx.doi.org/10.1016/j.ijcard.2015.03.208 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
insurances and mortgages applications in adults with CHD in comparison to a reference group [8]. 1. Methods Data were derived from a questionnaire which was sent to a random selection of adults with CHD from five hospitals (i.e., two tertiary referral centers and three regional centers) participating in the Dutch nationwide CONgenital CORvitia (CONCOR) registry. CONCOR facilitates research on the course and outcome of adult CHD [9]. Between 2001 and 2013, over 14,000 adults with CHD were included in CONCOR after providing informed consent. Data collection for this study ran from June 2013 until September 2014. The questionnaire included information on demographic items (i.e., sex, age, educational, occupational and relational status) and on applications and potential constraints for a health, disability or life insurance or mortgage. Results were compared to those from a reference group, obtained from the personnel of the participating hospitals, several random companies, administration organizations and people randomly passing by. Additional medical information on cardiac function, functional class and performance status was collected to search for clinical characteristics associated with constraints in the application. Under Dutch law, ethical approval for questionnaire studies is not required. Statistical analyses included the Chisquare test for categorical variables and the Mann–Whitney U test for continuous variables. All data were analyzed per CHD severity (i.e., mild or moderate to severe). Multivariable logistic regression analyses were performed adjusted for age, sex and socioeconomic status (i.e., educational and occupational attainment) and presented as odds ratios (ORs) with 95% confidence intervals (CI). Associations were considered significant if the 95% CI did not cover the value 1. The level of statistical significance was set at a p ≤ 0.05. Statistical analyses were conducted with the Statistical Package for the Social Sciences (SPSS, version 21.0, Inc., Chicago, IL, USA). 2. Results Of the 406 randomly selected patients, 237 patients completed the questionnaire (response rate 58%). Twenty patients refused to
94
M.A. Sluman et al. / International Journal of Cardiology 186 (2015) 93–95
Table 1 Socio-demographic characteristics of the study population.
Female sex, N (%) Age, median (IQR), y Personal situation, N (%): In a relationship Divorced/single/unmarried/widowed Other/unknown Education, N (%): Low (only primary school or other lower education) Higher (higher or academic education) Daily occupation, N (%): Employed Full-time paid job Part-time paid job Unemployed/job seeking Disabled Student/retired Homemaker Other CHD distribution, N (%): Mild Moderate Severe Distribution of defects, N (%) Repaired PDA/ASD/VSD Small PDA/ASD/VSD TOF CoA pulmonary valve disease Isolated aortic valve disease Marfan syndrome TGA Fontan/univentricular heart Ebstein's anomaly AVSD Other
CHD group
Reference group
p-Value
N = 237
N = 179
131 (55) 41 (31–50)
106 (59) 43 (32–54)
0.421 0.207
165 (70) 64 (27) 8 (3)
131 (73) 47 (26) 1 (1)
0.139
146 (63)
63 (35)
b0.001
84 (37)
116 (65)
153 (65) 84 (55) 69 (45) 8 (3) 25 (11) 27 (11) 12 (5) 12 (5)
158 (88) 100 (63) 58 (37) 1 (1) 1 (1) 15 (8) 4 (2) 0
0.002
96 (40) 123 (52) 18 (8)
– – –
–
42 (18) 30 (13) 26 (11) 25 (10) 21 (9) 28 (12) 16 (7) 9 (4) 6 (2) 4 (2) 3 (1) 27 (11)
– – – – – – – – – – – –
–
IQR = interquartile range; PDA = patent ductus arteriosus; ASD = atrial septal defect; VSD = ventricular septal defect; TOF = tetralogy of Fallot; CoA = aortic coarctation; TGA = transposition of great arteries; AVSD = atrioventricular septal defect.
participate, 16 were unable to participate and 7 were lost to follow-up. The remaining 126 patients never responded to our call for participation. Nonresponse analysis showed that responders were more often women (55% versus 39%, p b 0.001) and were older (median age 41 versus 36 years, p = 0.012). However, CHD severity did not differ significantly between responders and non-responders (p = 0.950). The main socio-demographic characteristics of the patients and the reference group and the distribution of the most frequent CHD diagnoses are outlined in Table 1. Employment rates were significantly lower in patients with CHD as compared to the reference group (65% versus 88%, p = 0.002). Of all patients with CHD, 40% had mild, 52% had moderate and 8% had severe CHD. The results from the questions on insurance and mortgage applications are displayed in Table 2. Insurance and mortgage application rates were significantly lower for all patients with CHD compared to the reference group, but did not differ among the different CHD severity groups. Lower disability insurance rates among patients were most likely attributable to lower employment rates. In total, 38% of patients with CHD experienced constraints in any application versus only 9% in the reference group (p b 0.001). Participants with and without constraints did not differ in age, sex, educational or employment status. Most constraints were encountered for patients with CHD in life insurance applications with significant differences in CHD severity. More specifically, patients with more severe CHD experienced more limitations (33% versus 56%, p = 0.009), of whom the majority (56%) had to pay a higher premium. Twenty percent of patients were declined for a life insurance, 15% were eventually accepted and 9% found other solutions such as an adjusted sum assured. In total, of only 38% of CHD patients medical information was requested from their treating physician. Among patients who had experienced limitations in the application process, this was the case in 70%. Additional medical information did not lead to different outcomes or other patterns in constraints and CHD severity. Only 10% of all patients who experienced limitations contacted a CHD patient association or other institution for help or advice. The association of two clinical parameters, functional New York Heart Association (NYHA) classification and left ventricular (LV) ejection fraction, with restrictions in insurance or mortgage applications was studied in 163 patients. After adjustment for age, sex, type of cardiac defect, occupational and relational status, restrictions were not associated with clinical parameters.
Table 2 Reported restrictions in insurance and mortgage application. CHD
REF N = 179
p-Valuea
p-Valueb
Adjusted ORc (95% CI)
Mild N = 96
Moderate to severe N = 141
Total N = 237
Any problem Applied, N (%) Restrictions, N (%)
90 (94) 31 (34)
126 (89) 51 (40)
216 (91) 82 (38)
174 (97) 15 (9)
0.243 0.538
0.011 b0.001
8.3 (4.3–15.9)
Health insurance Applied, N (%) Restrictions, N (%)
86 (90) 6 (7)
111 (79) 11 (10)
197 (83) 17 (9)
170 (95) 6 (4)
0.036 0.467
b0.001 0.014
3.6 (1.3–9.9)
Disability insurance Applied, N (%) Restrictions, N (%)
40 (42) 7 (18)
45 (32) 10 (22)
85 (35) 17 (20)
108 (60) 2 (2)
0.145 0.587
b0.001 0.003
11.8 (2.4–58.5)
Life insurance Applied, N (%) Restrictions, N (%)
58 (60) 19 (33)
72 (51) 40 (56)
130 (55) 59 (45)
127 (71) 3 (2)
0.180 0.009
0.002 b0.001
47.7 (13.4–170.0)
Mortgage Applied, N (%) Restrictions, N (%)
64 (67) 14 (22)
76 (54) 18 (24)
139 (59) 32 (23)
131 (73) 4 (3)
0.054 0.800
0.006 b0.001
8.4 (2.8–25.5)
CHD = congenital heart disease, REF = reference group, OR = odds ratio, CI = confidence interval. a Comparison of different CHD severities. b Comparison of total patient group to reference group. c Adjusted for age, sex, application, education and job.
M.A. Sluman et al. / International Journal of Cardiology 186 (2015) 93–95
3. Discussion and conclusion This study shows that favorable prognostic clinical factors in patients with CHD as mild defects, normal NYHA class and LV ejection fraction do not protect against constraints in insurance or mortgage applications. Despite the overall improved morbidity and prognosis, adults with CHD encountered more limitations than a reference group from the general population [10]. Providing clinical information was not associated with a reduction in constraints. Hence, clinical information did not seem to improve insight or transparency in the application process. Nowadays, accurate prognostication for most patients with CHD based on individual clinical information is possible [10,11]. We should continue to support patients in making sure essential medical information is provided and encourage insurance companies to base their decisions on clinical and epidemiological outcomes. In conclusion, there still seems to be an important gap between knowledge on CHD and transparency of the insurance application process. Applying for insurance shouldn't be so uncertain. Conflict of interest None. References [1] A.C. Zomer, I. Vaartjes, C.S. Uiterwaal, et al., Social burden and lifestyle in adults with congenital heart disease, Am. J. Cardiol. 109 (2012) 1657–1663. [2] J.L. Harrison, C.K. Silversides, E.N. Oechslin, A.H. Kovacs, Healthcare needs of adults with congenital heart disease: study of the patient perspective, J. Cardiovasc. Nurs. 26 (2011) 497–503.
95
[3] A.J. Marelli, A.S. Mackie, R. Ionescu-Ittu, E. Rahme, L. Pilote, Congenital heart disease in the general population: changing prevalence and age distribution, Circulation 115 (2007) 163–172. [4] P. Moons, L. Bovijn, W. Budts, A. Belmans, M. Gewillig, Temporal trends in survival to adulthood among patients born with congenital heart disease from 1970 to 1992 in Belgium, Circulation 122 (2010) 2264–2272. [5] M. Groenink, T.A. Lohuis, J.G. Tijssen, et al., Survival and complication free survival in Marfan's syndrome: implications of current guidelines, Heart 82 (1999) 499–504. [6] A. Kempny, R. Fernandez-Jimenez, O. Tutarel, et al., Meeting the challenge: the evolving global landscape of adult congenital heart disease, Int. J. Cardiol. 168 (2013) 5182–5189. [7] D.S. Crossland, S.P. Jackson, R. Lyall, et al., Life insurance and mortgage application in adults with congenital heart disease, Eur. J. Cardiothorac. Surg. 25 (2004) 931–934. [8] S. Apers, A.H. Kovacs, K. Luyckx, et al., Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart Disease—International Study (APPROACH-IS): rationale, design, and methods, Int. J. Cardiol. 179 (2015) 334–342. [9] E.T. van der Velde, J.W. Vriend, M.M. Mannens, C.S. Uiterwaal, R. Brand, B.J. Mulder, CONCOR, an initiative towards a national registry and DNA-bank of patients with congenital heart disease in the Netherlands: rationale, design, and first results, Eur. J. Epidemiol. 20 (2005) 549–557. [10] C.L. Verheugt, C.S. Uiterwaal, E.T. van der Velde, et al., Mortality in adult congenital heart disease, Eur. Heart J. 31 (2010) 1220–1229. [11] C.L. Verheugt, C.S. Uiterwaal, D.E. Grobbee, B.J. Mulder, Long-term prognosis of congenital heart defects: a systematic review, Int. J. Cardiol. 131 (2008) 25–32.
